Provider Demographics
NPI:1720267651
Name:MATHIS, TRACIE KENNON (RD/LD IBCLC)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:KENNON
Last Name:MATHIS
Suffix:
Gender:F
Credentials:RD/LD IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8710 S 71ST EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5053
Mailing Address - Country:US
Mailing Address - Phone:918-494-6455
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-230-6409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-27
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD932133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered